Low prevalence of atrial fibrillation in asymptomatic adults in Geneva, Switzerland.

AIMS: To determine the prevalence of atrial fibrillation (AF) in a population-based sample of adults. METHODS AND RESULTS: Between January 2005 and December 2007 individuals aged > or =50 years, residents of the city of Geneva, who had participated in a previous random survey were invited for follow-up examination. AF was assessed on a single resting 6-lead ECG. Reported prevalences were standardized for the age distribution of Canton Geneva. Overall participation was 72.8%. Twenty-nine cases of AF (22 men) were diagnosed among 3285 subjects (1696 men). The crude prevalence of AF (95% CI) was 0.88% (0.86, 0.90) overall, but higher in men [1.30% (1.26, 1.34)] than in women [0.44% (0.41, 0.47)]. The age-standardized AF prevalence was slightly higher [overall: 0.94% (0.91, 0.97), men: 1.23% (1.19, 1.27), women: 0.54% (0.47, 0.61)]. AF prevalence increased with age in both sexes. A 'history of suspected arterial embolism' (brain or legs) was higher in the AF cases (10.3 vs. 3.3%; P = 0.03). CONCLUSION: This population-based survey of a general Swiss population indicates that the prevalence of AF remains below 1%. These results are less alarming than those from previous studies based on patients seeking medical care.

Atrial fibrillation in Africa: clinical characteristics, prognosis, and adherence to guidelines in Cameroon.

AIMS: The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in the urban population of a sub-Saharan African country and to assess how successfully current guidelines are applied in that context. METHODS AND RESULTS: This prospective study involved 10 cardiologists in Cameroon. Enrolment started on 1 June 2006 and ended on 30 June 2007. Consecutive patients were included if they were >18 years and AF was documented on an ECG during the index office visit. In this survey, 172 patients were enrolled (75 males and 97 females; mean age 65.8 +/- 13 years). The prevalence of paroxysmal, persistent, and permanent AF was 22.7, 21.5, and 55.8%, respectively. Underlying cardiac disorders, present in 156/172 patients (90.7%), included hypertensive heart disease (47.7%), valvular heart disease (25.6%), dilated cardiomyopathy (15.7%), and coronary artery disease (6%). A rate-control strategy was chosen in 83.7% of patients (144 of 172) and drugs most commonly used were digoxin and amiodarone. The mean CHADS(2) score was 1.9 +/- 1.1 and 158 of 172 patients (91.9%) had a CHADS(2) score > or =1. Among patients with an indication for oral anticoagulation (OAC), only 34.2% (54 of 158) actually received it. During a follow-up of 318 +/- 124 days, 26 of 88 patients died (29.5%), essentially from a cardiovascular cause (15 of 26). Ten patients (16.1%) had a non-lethal embolic stroke and 23 (26.1%) had symptoms of severe congestive heart failure. CONCLUSION: Clinical presentation of AF in Cameroon is much more severe than in developed countries. A rate-control strategy is predominant in Cameroon and OAC is prescribed in only 34.2% of eligible patients, despite a high CHADS(2) score at inclusion. Death and stroke rate at 1 year are very high in Cameroon possibly because of a lower use of OAC, and a higher prevalence of rheumatic mitral disease and of more severe co-morbidities.

Atrial fibrillation management by practice cardiologists: a prospective survey on the adherence to guidelines in the real world.

AIMS: The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in cardiology practice and to assess how successfully guidelines have been implemented in real-world practice. METHODS AND RESULTS: This prospective study involved 23 cardiologists established in office practice in Geneva. Enrollment started on 1 January 2005 and ended on 31 December 2005. Consecutive patients were included if they were >18 years and had AF documented on an ECG during the index office visit or during the preceding month. In this survey, 622 ambulatory patients were enrolled (390 males and 232 females; mean age 69.8 +/- 11.8 years). The prevalence of paroxysmal, persistent, and permanent AF was 35, 18, and 47%, respectively. Underlying cardiac disorders present in 513 patients (82%) included hypertensive heart disease (30%), valvular heart disease (27%), coronary artery disease (18%), and myocardial disease (11%). A rate-control strategy was chosen in 53% of the patients (331/622). The mean CHADS(2) score was 1.43 +/- 1.24, and 458/622 patients (73.6%) had a CHADS(2) score >or=1. Among patients with an indication to oral anticoagulant therapy (OAT), 88% (403/458) effectively received it. The rate of OAT was closely correlated with an increasing CHADS(2) score, particularly with patients age (72, 81, and 87% for patients <65, 65-75, and >75 years of age, respectively). True contraindication for OAT was present in 4% (18/458). In the low-risk group (CHADS(2) score = 0), 58% were prescribed OAT, but in 37% of them only for a short period of time (cardioversion/ablation). After a follow-up of 396 +/- 109 days, 72% of the study group (410/570) was still treated by OAT. During follow-up, 23/570 patients died (4%), essentially from a cardiovascular cause (15/23), 15 had a non-lethal embolic stroke (2.7%), and 8 had significant bleeding complications (1.5%). CONCLUSION: This study shows one of the highest OAT prescription rates for AF reported until now and demonstrates how successfully guidelines can be applied in the real world. A definite overinterpretation of current guidelines is observed in low-risk patients with AF. True contraindication for OAT (4%) and significant bleeding during OAT (1.5%) were rare.

Value of the 12-lead resting electrocardiogram for the diagnosis of previous myocardial infarction in paced patients.

AIM: This study was conducted to assess the clinical value of the 12-lead electrocardiogram (ECG) for the diagnosis of previous myocardial infarction (MI) in permanently paced patients. METHODS: A total of 107 unselected patients with permanent pacemakers were retrospectively studied and divided into 3 groups: group 1 (control group): 38 patients without a history of MI (mean age, 67 +/- 16 years; 20 men; ejection fraction 63% +/- 8%); group 2: 44 patients (mean age, 72 +/- 11 years; 41 men) with documented previous MI (21 anterior, 23 inferior; ejection fraction 38% +/- 13%; P < .0001 vs group 1); group 3: 25 patients (mean age, 71 +/- 14 years; 24 men) with biventricular pacing for severe heart failure (16 ischemic, 9 nonischemic; ejection fraction 28% +/- 8%; P = .001 vs group 2, P < .0001 vs group 1). A surface 12-lead ECG with full ventricular capture was used for analysis. Comparing group 1 and group 2, the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of 5 criteria was calculated: (1) Cabrera's sign (notching in the ascending limb of the S wave in lead V(3), V(4), or V(5)); (2) Chapman's sign (notching of the R wave in lead I, aVL, or V(6)); (3) presence of a qR in lead I, aVL, or V(6); (4) notching of QRS in lead II, III, or aVF; (5) presence of a qR in lead II, III, or aVF. RESULTS: To detect prior MI, sensitivity was moderate for Cabrera's sign (63.6%) and poor for all other ECG criteria ranging from 9.1% to 40.9%. Specificity was relatively high for all ECG criteria ranging from 81.6% to 100%. Combining all 5 ECG signs increased sensitivity to 86.4%, with a specificity of 65.8% and an overall accuracy of 76.8% for the diagnosis of previous MI. None of the 5 criteria was particularly useful to assess the site of prior MI. In patients with biventricular pacing, the accuracy of the 5 ECG criteria was poor and the presence of a qR wave in lead I, aVL, or V6 appears nonspecific and related to pacing site. CONCLUSION: The ECG diagnosis of previous MI in paced patients remains a difficult challenge but the presence of 1 or more of the aforementioned ECG criteria may be clinically useful to detect previous MI, suggesting that these ECG signs should be widely taught during medical training. However, in patients with biventricular pacing, these ECG signs are of no value.

[Management of atrial flutter in 2006]. / Flutter auriculaire: le point en 2006.

Typical or common atrial flutter is a frequent cardiac arrhythmia related to a macroreentrant circuit located entirely within the right atrium. Risks associated with this supraventricular arrhythmia include 1 to 1 conduction with extremely rapid ventricular rates, tachycardia-mediated cardiomyopathy and thromboembolic events. Treatment of choice of atrial flutter is radiofrequency catheter ablation of the cavo-tricuspid isthmus, and this form of treatment may be considered either during the first episode or at the time of the first recurrence of atrial flutter. Anticoagulant therapy is the rule in the presence of atrial flutter because this arrhythmia favors thromboembolic complications and because atrial flutter is frequently associated with atrial fibrillation.

Atrioventricular nodal reentrant tachycardia in the elderly: efficacy and safety of radiofrequency catheter ablation.

BACKGROUND: Radiofrequency (RF) catheter ablation is considered the treatment of choice for patients with atrioventricular nodal reentrant tachycardia (AVNRT). This study examined the efficacy and safety of RF ablation in patients with AVNRT >/= 65 years of age. METHODS: We retrospectively analyzed data collected in 350 consecutive patients who underwent AVNRT RF ablation between 1995 and 2005. They were divided according to whether they were < 65 years (Group 1, n = 280; mean age = 46 +/- 13 years, 69% women) or >/= 65 years (Group 2, n = 70; mean age = 72 +/- 6 years, 59% women) of age. RESULTS: Patients in Group 2 more often had structural heart disease (12/70 vs 17/280, P = 0.002) than in Group 1, though there was no difference in the prevalence of syncope (6/70 vs 18/280, P = 0.52) or atrial fibrillation (1/70 vs 6/280, P = 0.70) between the 2 groups. Before RF ablation, patients in Group 2 had a longer mean A-H intervals (90 +/- 31 ms vs 77 +/- 19 ms, P < 0.0001), H-V intervals (44 +/- 6 ms vs 41 +/- 5 ms, P < 0.0001), fast pathway refractory period (358 +/- 14 ms, vs 335 +/- 68 ms, P = 0.01), and tachycardia cycle length (394 +/- 71 ms vs. 335 +/- 59 ms, P < 0.0001). A > 140 ms A-H interval was present in 3/70 patients in Group 2 versus 0/280 in Group 1 (P < 0.001). No difference was observed between the 2 groups in primary RF ablation success rate (70/70 vs 277/280, P = 0.38), overall procedure duration (75 +/- 35 minute vs 78 +/- 43 minute, P = 0.61), duration of fluoroscopic exposure (14 +/- 12 minute vs 13 +/- 12 minute, P = 0.63), or number of RF pulses (median 5 vs 4, P = 0.051). Two patients in Group 1 (0.57%) developed 3rd degree AV block requiring permanent pacing. Recurrences of AVNRT were limited to Group 1 (16/280 vs 0/70, P = 0.001). CONCLUSIONS: RF ablation of AVNRT was highly effective and safe in patients >/= 65 years of age despite a higher prevalence of structural heart disease and longer A-H intervals at baseline. RF ablation might be considered as first-line therapy for the elderly with AVNRT.

Permanent form of junctional reciprocating tachycardia in adults: peculiar features and results of radiofrequency catheter ablation.

AIM: PJRT occurs predominantly in infants and children and is limited to small series in adults. The aim of this study was to describe the clinical presentation, electrophysiological characteristics, feasibility and safety of radiofrequency ablation, and the long-term prognosis in a large group of adult patients with the permanent form of junctional reciprocating tachycardia (PJRT). METHODS AND RESULTS: Forty-nine adult patients (22 male and 27 female; mean age 43+/-16) with a diagnosis of PJRT confirmed at electrophysiological study were included. Eight patients (16%) presented with tachycardia-induced cardiomyopathy (TIC). Ventricular rate was 146+/-30 bpm. The arrhythmia was permanent or incessant in 23/49 cases (47%) and paroxysmal in 26/49 (53%). A significant correlation was found between symptom duration and tachycardia rate (r(2)=0.12, P=0.01). The accessory pathway (AP) was located in the right posteroseptal region in 37 cases (76%) and in atypical sites in 12 cases (24%). Patients with the incessant or permanent form of PJRT had longer duration of symptoms, more frequently TIC and a slower tachycardia rate. Radiofrequency catheter ablation was initially successful in 46 cases (94%) without any serious complication. Long-term success rate was 100% (49/49 patients) in the absence of any antiarrhythmic drug treatment (mean follow-up 49+/-38 months). Regression of TIC was observed in all cases (8/8). CONCLUSION: PJRT in adults is often paroxysmal (53%), and the retrograde slowly conducting, decremental AP is not infrequently in a non-posteroseptal location. Radiofrequency catheter ablation is highly effective and should be considered as the treatment of first choice in adult patients with PJRT.